Medical History Form - Adult (Over 18 Years of Age)

Name:

Preferred Pronouns*

He/Him She/Her They/Them

Home Address*

Post Code*

Mobile Phone*

Email*

Date of Birth*

Occupation

Emergency Contact/Guardian Name*

Emergency Contact Number*

Emergency Contact Relationship to you*

Parent Partner Friend Other

How did you hear about us?*

From a friend/family Signage/Walked past Google Facebook Medibank Other

Please provide their name so we can thank them:

Please specify:

Are you a member of a health fund?*

Yes No

Please specify:

Name of your General Practitioner (GP) doctor or clinic

Are you currently pregnant?*

Yes No

If yes, how many weeks?

Have you had any serious illnesses in the last 2 years?*

Yes No

If yes, which one?

Are you currently taking any medications or tablets regularly?*

Yes No

If yes, what for?

Do you have any allergies? e.g. Latex, medications*

Yes No

If yes, please describe:

Do you smoke or vape?

Yes No In the past

If Yes, how many/often per day?

If In the past, how many years ago did you quit?

Have you ever been told you snore?*

Yes No

If yes, how often?

Dental History

Are you fearful of dental treatment?*

Not at all Little Somewhat Very

I see my dentist every*

6 months 12 months Irregularly First time

Dental Treatment History

Have you ever had…

An unfavorable dental experience?*

Yes No

Have you ever had braces or orthodontic treatment?*

Yes No

If yes, when did you start?

Any teeth removed, including wisdom teeth?*

Yes No

Which ones?

Any fillings in the past? If yes, how many?*

1-5 5-10 10+ None

Any root canal treatment?*

Yes No

Gums & Jaw Bone

Do your gums bleed when brushing or flossing?*

Yes No

Have you ever been treated for gum disease or bone loss around teeth?*

Yes No

Have you ever noticed an unpleasant taste or odor in your mouth?

Yes No

Bite and Jaw Joint

Do you have any issues with your jaw joint such as pain, limited opening, locking, or popping?*

Yes No

Please specify:

Do you clench or grind your teeth in the day or at night?*

Yes No

Trauma

Have you ever had any injuries to your mouth or teeth?

Yes No

Have you ever fallen and bumped your chin, or received a blow to your jaw?

Yes No

Habits

Do/did you have any of the following habits?

Finger / Thumb sucking Lip biting Nail biting Ice chewing Other None

Describe if you have any other habits.

Consent for Services and Signature

I, the undersigned, provide consent for the following:
Dental Procedures: I consent to the use of dental procedures available to perform the necessary and/or advisable dental treatment options I choose, including the use of imaging and local anaesthetics.* This field is required.
Cancellation Policy: I understand that the practice requires at least 24 hours' notice for appointment cancellations. If I fail to do so, a cancellation fee of $75.00 may apply.* This field is required.
Use of Dental Images: I consent to the use of my non-identifiable dental images, models or x-rays for educational and marketing purposes.
Payment Policy: I accept responsibility for associated fees with the treatment option I choose, which are informed before any treatment starts. I acknowledge that payment is required on the day of treatment and that a pre-arranged payment plan is also available to me.* This field is required.
I have read and agree to the terms and conditions above.* This field is required.

Please sign below: